Health reform • Work group offers first look at possible expansion options for Utah.

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A community work group carving out ideas to put a unique Utah stamp on the rules for Medicaid under the Affordable Care Act is drafting a wide range of state options  from a full expansion with a tailored set of benefits to a hybrid program that marries a traditional public program with income-based tax subsidies for the poor.

"If you turn any of these proposals over, you'd see that 'made in the Beehive State label,' " Jason Cook, interim director of the Utah Heath Policy Project, told the Medicaid Expansion Options Community Workgroup on Thursday.

Utah is among a handful of states still considering whether to expand Medicaid next year. The decision rests with Gov. Gary Herbert, who in April tasked the group with drilling into the details to provide the state with options to the mandates of the federal law.

The public got a first look at the proposals in progress on Thursday at the Capitol, and a final report is expected in late September.

Under the ACA, most Americans must get health insurance by 2014 either through public programs or private insurance. The law gives states the option of expanding Medicaid eligibility to draw in more low-income citizens. In states that opt for full expansion, the federal government will pay 100 percent of those costs through 2017. After that, states will pay a share, but the law caps those expenses at 10 percent of overall costs.

Utah's Republican lawmakers oppose a full Medicaid expansion, which would cover those earning up to 138 percent of the poverty level  about $32,000 for a family of four  while advocates for the poor and some medical providers favor it.

Up to 123,000 of Utah's 400,000 low-income uninsured would get coverage under Medicaid expansion. Utah can also decide not to expand its Medicaid program but would lose some of its federal tax dollars to fund expansion in other states.

Composed of business leaders, advocates for the poor, medical professionals and state lawmakers, the work group is divided into five subcommittees, each with specific themes to consider. Among those are expanding charity care programs to cover more of the uninsured, offering subsidies to people buying private insurance andusing Medicaid funding like a block grant to pay for a program with a mix of features, including traditional Medicaid, managed care and health savings accounts.

That hybrid approach and the use of subsidies to keep Utahns in the private insurance market emerged as clear themes in all of Thursday's presentation.

Some are original in their scope. Others draw on plans proposed in other states. All keep in mind a prime consideration: the financial and social impact each proposal would have on the state, including which Utahns might still fall through coverage cracks.

Another theme: Full expansion during the first three years, when the federal government will pay 100 percent of costs, followed by working to design a program that would win federal government approval for implementation in 2017.

Any alternative to a straight ACA-mandated full expansion will require federal approval, and it's not yet clear how the proposals in the works might fare. Utah Health Department Executive Director David Patton doesn't think the proposals give the governor a false choice.

"If we prepare a plan that is a reasonable plan, I think [the federal government] will consider it seriously and even then, we can still work with them," he said. "I think anything that is reasonable is possible."

The proposals will also have to pass muster with the Utah Legislature.

"The main challenge is that we have to marry Utah policy with federal policy," Rep Jim Dunnigan, R-Taylorsville, who also co-chairs the state's Health Care Reform Task Force, said. "So far, I don't think we're at Utah policy."

Cook, however, said he thinks a hybrid approach that taps into three years of full federal funding before moving to a Utah-designed model is "sellable." The approach would give Utah time to build the system it wants.

"Implementation takes time," Cook said. "Now is the time to get the real work question of how long does it take to build this and what can we do in the meantime to take advantage of the financial side of this to get people into coverage and get them healthier, so that when we put them into a Utah-designed system the costs are lower."

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